Common use of Continued Stay Reviews Clause in Contracts

Continued Stay Reviews. Any involuntarily admitted individual will be reviewed by DMH Utilization Review Care Manager. Continued Stay Review periodicity will be determined by the DMH Utilization Review Care Manager. Designated Hospital’s (DH) will provide clinical information requested by the care manager in order to authorize the period of inpatient care during the period of time under review. Any continued stay review that appears to no longer meet inpatient or Level I patient clinical eligibility criteria will be referred to the DMH Care Manager assigned to the DH for concurrent review. Only after consultation between the DMH Care Manager and the DMH Utilization Review Care Manager with the DH utilization review representative, a continued stay determination will be made. The DMH Utilization Review Care Manager in consultation with the DMH Medical Director or Psychiatrist designee, and where clinically appropriate, will: • certify the continued stay as Level I involuntary • certify the continued stay as acute, voluntary or involuntary, and identify the continued stay review periodicity; or • certify the continued stay as “awaiting discharge” level of care and the basis for the determination; or • certify no inpatient level of care being met and issue payment denial. For DMH tracking purposes with Level I inpatient providers and bed utilization review, the aforementioned certifications for Continued Stay Reviews will: • Authorize Level I clinical eligibility criteria as being met and identify subsequent continued stay review date. Continuing Level I enhanced payment clinical eligibility criteria will consider intensity and duration of treatment services and routine documentation of: • the need for continued allocation of significant and more than usual resources to maintain the safety of the patient, other patients, or staff; • intractable mental illness symptomology, ongoing behavioral dysregulation and instability with demonstrated treatment plan modifications; • complex medication management that must occur in an acute inpatient setting; • active daily restorative interventions/services not available in alternate level of care settings. This authorization level maintains enhanced payment for inpatient billing and coding purposes; or • Authorize “acute” level of care (Level I patient remains acute, no longer requires additional level I resources, and internal transfer to other units is possible*) and effective date. This authorization level will be determined after having exhausted the clinical review process with the treatment team. (*If transfer to another unit cannot be mutually agreed to by both the Contractor and the DMH, the authorization level will be made and tracked by DMH, but enhanced payment will not be denied. Such determinations will be reviewed and any financial adjustments made during the annual cost reconciliation process.) The annual cost reconciliation process shall be the final determinant for any financial adjustment; or • Authorize “awaiting discharge” level of care (a former Level I patient is no longer acute and facility is actively working toward discharge) and effective date. Patients with complicated legal status or significant aftercare planning complexities may be in this level of care. This authorization level maintains payment for inpatient billing and will be tracked by DMH, but notifies providers of Level I units that acute clinical eligibility criteria is no longer met; or • Deny awaiting discharge clinical eligibility criteria as being met and level of care change effective date. This determination will only be made when transfer to an alternative level of care is appropriate and has been offered and declined by the inpatient facility. This determination will result in a denial of payment authorization for continued stay. Patients in Level I unit beds, who continue to require psychiatric support services but are determined to be eligible for internal transfer or “awaiting discharge” as outlined above, are a priority group for aftercare coordination and movement to either alternate inpatient units or alternate care settings when clinically appropriate. It is an expectation that hospitals will actively collaborate with DMH Care Managers to effect clinically appropriate inpatient movement or discharges to receiving facilities to expedite clinically appropriate level of care and aftercare when a patient does not meet Level I clinical eligibility criteria. Enhanced payment and inpatient level of care authorizations will not be made if an appropriate alternative level of care, as determined by DMH and clinical staff of Contractor, has been offered and declined by the inpatient facility. Enhanced payment and inpatient level of care authorizations are contingent upon actively transitioning identified patients who no longer meet the level of care for Level I inpatient services to an available unit or facility that will accept a patient for admission.

Continued Stay Reviews. Any individual involuntarily admitted individual to Tyler 4 will be reviewed by DMH State Utilization Review Care Manager. Continued Stay Review periodicity will be determined by the DMH Utilization Review Care Manager. Designated Hospital’s (DH) The Contractor will provide clinical information requested by the care manager in order Utilization Reviewer to authorize the period of inpatient care during the period of time under review. Any continued stay review that appears to no longer meet inpatient or Level I patient clinical eligibility criteria will be referred to the DMH State Care Manager assigned to the DH DMH for concurrent review. Only after consultation between the DMH Care Manager and review between the DMH Utilization Review Care Manager with the DH DMH utilization review representative, a continued stay determination will be made. The DMH Utilization Review Care Manager in consultation with the DMH Medical Director or Psychiatrist designee, and where clinically appropriate, designee will: • certify the continued stay as Level I involuntary • certify the continued stay as acute, voluntary or involuntary, and identify the continued stay review periodicity; or • certify the continued stay as “awaiting discharge” level of care and the basis for the determination; or • certify no inpatient level of care being met and issue payment denial. For DMH tracking purposes with Level I inpatient providers providers, and evaluation of Level I inpatient bed utilization reviewfor annual real, actual cost reconciliation, the aforementioned certifications for Continued Stay Reviews will: • Authorize Level I clinical eligibility criteria as being met and identify subsequent continued stay review date. Continuing Level I enhanced payment clinical eligibility criteria will consider intensity and duration of treatment services and routine documentation of: • the ▪ The need for continued allocation of significant and more than usual resources to maintain the safety of the patient, other patients, or staff; • ▪ intractable mental illness symptomology, ongoing behavioral dysregulation and instability with demonstrated treatment plan modifications; • ▪ complex medication management that must occur in an acute inpatient setting; • ▪ active daily restorative interventions/services not available in alternate level of care settings. This authorization level maintains enhanced payment for inpatient billing and coding purposes; or • Authorize “acute” level of care (Level I patient remains acute, no longer requires additional level Level I resources, and internal transfer to other units is possible*) and effective date. This authorization level will be determined after having exhausted maintains eligibility for inpatient payment at the clinical review process with established 76.4 % reimbursement rate outlined in the treatment teampayment provisions (Attachment B). (*If transfer to another unit cannot be mutually agreed to by both the Contractor and the DMHState, the authorization level will be made and tracked by DMHState, but enhanced payment will not be denied. Such determinations will be reviewed reviewed, and any financial adjustments made during the annual cost reconciliation process.) The annual cost reconciliation process shall be the final determinant for any financial adjustment); or • Authorize “awaiting discharge” level of care (a former Level I patient is no longer acute acute, and facility is actively working toward discharge) and effective date. Patients with complicated legal status or significant aftercare planning complexities may be in this level of care. This authorization level maintains payment for inpatient billing and will be tracked by DMHState, but notifies providers of Level I units that acute clinical eligibility criteria is no longer met; or • Deny awaiting discharge clinical eligibility criteria as being met and level of care change effective date. This determination will only be made when transfer to an alternative level of care is appropriate and has been offered and declined by the inpatient facility. This determination will result in a denial of payment authorization for continued stay. Patients in Level I unit beds, who continue to require psychiatric support services but are determined to be no longer require Level 1 services, are eligible for internal transfer or “awaiting discharge” as outlined above, are a priority group should be prioritized by the hospital and State Care Management for aftercare coordination and movement to either alternate inpatient units or alternate care settings when clinically appropriatesettings. It is an expectation that hospitals will Hospitals shall actively collaborate with DMH State Care Managers to effect clinically appropriate inpatient movement transfers to other units within the hospital or discharges to receiving facilities to expedite clinically appropriate level of care and aftercare when a patient does not meet Level I clinical eligibility criteria. Enhanced payment and inpatient level of care authorizations will not be made if an appropriate alternative level of care, as determined by DMH and clinical staff of Contractor, has been offered and declined by the inpatient facility. Enhanced payment and inpatient level of care authorizations are contingent upon actively transitioning identified patients who no longer meet the level of care for Level I inpatient services to other units or an available unit or facility that will accept a patient for admission.

Continued Stay Reviews. Any involuntarily admitted individual will be reviewed by DMH Utilization Review Care Manager. Continued Stay Review periodicity will be determined by the DMH Utilization Review Care Manager. Designated Hospital’s (DHHospital’s(DH) will provide clinical information requested by the care manager in order to authorize the period of inpatient care during the period of time under review. Any continued stay review that appears to no longer meet inpatient or Level I patient clinical eligibility criteria will be referred to the DMH Care Manager assigned to the DH for concurrent review. Only after consultation between the DMH Care Manager and review between the DMH Utilization Review Care Manager with the DH utilization review representative, a continued stay determination will be made. The DMH Utilization Review Care Manager in consultation with the DMH Medical Director or Psychiatrist designee, and where clinically appropriate, designee will: •  certify the continued stay as Level I involuntary •  certify the continued stay as acute, voluntary or involuntary, and identify the continued stay review periodicity; or •  certify the continued stay as “awaiting discharge” level of care and the basis for the determination; or •  certify no inpatient level of care being met and issue payment denial. For DMH tracking purposes with Level I inpatient providers providers, and evaluation of Level I inpatient bed utilization reviewfor annual real, actual cost reconciliation, the aforementioned afore mentioned certifications for Continued Stay Reviews will: •  Authorize Level I clinical eligibility criteria as being met and identify subsequent continued stay review date. Continuing Level I enhanced payment clinical eligibility criteria will consider intensity and duration of treatment services and routine documentation of: • the  The need for continued allocation of significant and more than usual resources to maintain the safety of the patient, other patients, or staff; •  intractable mental illness symptomology, ongoing behavioral dysregulation and instability with demonstrated treatment plan modifications; •  complex medication management that must occur in an acute inpatient setting; •  active daily restorative interventions/services not available in alternate level of care settings. This authorization level maintains enhanced payment for inpatient billing and coding purposes; or •  Authorize “acute” level of care (Level I patient remains acute, no longer requires additional level I resources, and internal transfer to other units is possible*) and effective date. This authorization level will be determined after having exhausted the clinical review process with the treatment team. (*If transfer to another unit cannot be mutually agreed to by both the Contractor and the DMH, the authorization level will be made and tracked by DMH, but enhanced payment will not be denied. Such determinations will be reviewed and any financial adjustments made during the annual cost reconciliation process.) The annual cost reconciliation process shall be the final determinant for any financial adjustment; or •  Authorize “awaiting discharge” level of care (a former Level I patient is no longer acute and facility is actively working toward discharge) and effective date. Patients with complicated legal status or significant aftercare planning complexities may be in this level of care. This authorization level maintains payment for inpatient billing and will be tracked by DMH, but notifies providers of Level I units that acute clinical eligibility criteria is no longer met; or •  Deny awaiting discharge clinical eligibility criteria as being met and level of care change effective date. This determination will only be made when transfer to an alternative level of care is appropriate and has been offered and declined by the inpatient facility. This determination will result in a denial of payment authorization for continued stay. Patients in Level I unit beds, who continue to require psychiatric support services but are determined to be eligible for internal transfer or “awaiting discharge” as outlined above, are a priority group for aftercare coordination and movement to either alternate inpatient units or alternate care settings when clinically appropriate. It is an expectation that hospitals will actively collaborate with DMH Care Managers to effect clinically appropriate inpatient movement or discharges to receiving facilities to expedite clinically appropriate level of care and aftercare when a patient does not meet Level I clinical eligibility criteria. Enhanced payment and inpatient level of care authorizations will not be made if an appropriate alternative level of care, as determined by DMH and clinical staff of Contractor, has been offered and declined by the inpatient facility. Enhanced payment and inpatient level of care authorizations are contingent upon actively transitioning identified patients who no longer meet the level of care for Level I inpatient services to an available unit or facility that will accept a patient for admission.